Undergraduate and Accelerated MSN Pre-Licensure Preceptor Award | 2026
Individual Nomination Form
Your Personal Information
Name
*
First Name
Last Name
University of Cincinnati Email
*
example@mail.uc.edu
Preferred Phone Number
*
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nominee's Information
Nominee's Name
*
First Name
Last Name
Nominee's Email
*
example@example.com
Nominee's Job Title
*
Nominee's Employer
*
Please Select
Bon Secours Mercy Health
Cincinnati Children's Hospital
Cincinnati VA Medical Center
Kettering Health
St. Elizabeth Healthcare
The Christ Hospital
TriHealth
UC Health
Other
If you selected "Other," please specify the nominee's employer below.
Nominee's Site (e.g. UC West Chester Hospital, Mercy Fairfield Hospital, Cincinnati Children's Hospital Medical Center)
*
Nominee's Unit (If the nominee does not work on a hospital unit, answer N/A.)
*
Course or special program through which you worked with nominee
Please Select
Nursing Co-op Program (Cincinnati Children's or UC Medical Center)
Dedicated Education Units (NBSN 3110-C, NBSN 3130-C or AMSN 7032-C)
Population, Public and Community Health Nursing (NBSN3140-C or AMSN 7040-C)
Patient Centered Care for Adults with Complex Health Concerns (NBSN 4102-C or AMSN 7043-C)
Start Date of Precepted Experience with Nominee
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-
Month
-
Day
Year
Date
End Date of Precepted Experience with Nominee
*
-
Month
-
Day
Year
Date
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Describe how the nominee demonstrates a passion for and commitment to the role of preceptor. (Please provide specific examples.)
*
Describe how the nominee created a quality learning experience for you in the time this person served as your preceptor. (Please provide specific examples.)
*
Describe how your experience with this nominee as a preceptor has influenced your academic journey and your future role as a nurse.
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In a few words, how would you define the impact this precepted experience has had in your preparation as a registered nurse? (This is optional and does not impact your nomination.)
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Acknowledgement
*
I acknowledge that my responses could be used in future University of Cincinnati College of Nursing communications.
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